131003P - ETHICS AND PROFESSIONALISM IN MEDICAL EDUCATION

Presented at the International conference on medical education organized by Riphah International University in Mauritius on 5^rd October 2013 a by Professor Omar Hasan Kasule Sr. MB ChB(MUK), MPH (Harvard), DrPH (Harvard)

UNANIMITY ON THE IMPORTANCE OF ETHICS EDUCATION

·         PRIME 1 (Project to Rebalance and Integrate Medical Education) in 2010 undertook a critical appraisal of the definition, goals, and objectives of ethics education. Three main goals were identified (a) humanistic skills and professional conduct (b) Patient-centered skills (c) critical thinking skills.(Acad Med. 2012 Mar;87(3):334-41)

·         PRIME 11 in 2011 identified 3 themes; (a) professionalism central to physician education (b) professionalism will flourish after addressing dysfunction of the health (c) ethics and humanities must have a unity of vision and purpose on professionalism.(Acad Med. 2013 Sep 25)

·         Ethics education is needed in the education of medical professionals and science and technology must address the ethical issues of new innovations.(BMC Med Educ. 2013 Apr 23;13:58)

VARIATIONS IN TIME ALLOCATED TO ETHICS EDUCATION

·         In South East Europe: average is 27.1 per year.  In the European Union 44 hours for the whole curriculum(SciEng Ethics. 2013 Feb 23)

·         Pressure to pass exams in Japan associated with resistance to patient rights; no time for ethics education which is not examinable in written exams. (Tohoku J Exp Med. 2011;224(4):307-15)        

·         Residents reported receiving a moderate amount of ethics training during medical school and some ethics training during residency.(Acad Psychiatry. 2011 May-Jun;35(3):175-83)

·         Canadian family residence programs: Two-thirds of responding programs had less than 10 hours of scheduled instruction per year(Can Fam Physician. 2012 Dec;58(12):e751-6)

·         Time allocated to ethics is not enough but all disciplines say the same. Curriculosis if everybody had his/her way?

DIVERSITY OF CONTENTS OF ETHICS CURRICULA

·         Diversity of curricular contents. Attempt to standardization of the ethics curriculum in Japan(Med Law. 2012 Sep;31(3):365-74)

·         Recommended content of pre-health curricula: 1) humanities 2) mentoring 3) case study 4) service learning activities.  5)use of reflection and writing, discussions, and media.(Tex Dent J. 2011 Aug;128(8):698-706)

·         Suggested curriculum for emergency medicine: ethical principles, the physician-patient relationship, patient autonomy, clinical issues, end-of-life decisions, justice, education, research ethics, and professionalism(J Emerg Med. 2011 May;40(5):550-6)

·         An integrated medical ethics curriculum professionalized student attitudes(Ann Acad Med Singapore. 2011 Jan;40(1):4-18)

DIVERSITY OF METHODS / APPROACHES TO ETHICS EDUCATION

·         Teaching ethics in pre-health: reflection and writing, discussions, and media.(Tex Dent J. 2011 Aug;128(8):698-706)

·         A short lecture increased student’s awareness of plagiarism(J BUON. 2012 Jul-Sep;17(3):570-4) and increased knowledge and attitudes about science ethics(J BUON. 2012 Apr-Jun;17(2):391-5)

·         Teaching ethics by analysis of cases describing students’ experiences in clinical attachments (J Med Ethics. 2010 Dec;36(12):816-20).

·         Case-centred discussion of ethical dilemmas: approaches to analyzing ethical issues and developing a course of action for resolution(Int Rev Psychiatry. 2010;22(3):301-5).

·         Using ethics education as part of professional disciplinary actions(J Am Coll Dent. 2009 Fall;76(3):32-45)

·         interprofessional PBL curriculum of clinical ethics is practicable(Kaohsiung J Med Sci. 2013 Sep;29(9):505-1)but in Brunei we found it difficult to combine medical students with nursing students.

·         Other approaches: medical drama, (Med Teach. 2010;32(5):e205-10) TV medical programs,(BMC Med Educ. 2011 Jul 29;11:50) debates, (J Interprof Care. 2013 Sep 3) and web modules (J Am CollRadiol. 2012 Mar;9(3):170-3)

AWARENESS / KNOWLEDGE DO NOT TRANSLATE INTO ACTION

·         Gap between not thinking and not acting as a doctor on one hand and thinking of patients and fellow humans(Med Health Care Philos. 2013 Feb;16(1):13-8)

·         Medical researchers recognized various forms of scientific fraud but were not willing to whistle blow or punish the offenders(J BUON. 2011 Oct-Dec;16(4):771-7)

FEW SPECIALIST TEACHERS:

·         Most teachers are self-taught but a few masters programs are now available

·         NewYork-Presbyterian Hospital's graduated credentialing of clinical ethicists(J Clin Ethics. 2012 Summer;23(2):156-64)

·         Teachers of ethics must behave professionally(Dev World Bioeth. 2013 Feb 15)

·         Teachers misconceptions e.g. the principle of double effect (PDE) morphia for pain causing respiratory depression (a very rare incidence)(J Med Ethics. 2012 Mar;38(3):174-8)

·         Amateur teachers vs professional teachers

STUDENT CONCERNS

·         US Students and residents not comfortable handling more than 70% of ethical issues(J Med Ethics. 2013 Jan;39(1):55-8)

·         Egyptian students: 60% favored an integrated ethics throughout the medical course,  56% chose the practical problem solving strategies, 53.4% wanted specialised faculty, 69.3% wanted updated on confidentiality, doctor-patient relationship and informed consent (J Forensic Leg Med. 2011 Jul;18(5):204-7)

·         Despite teaching on ethics medical students in the clinical years lose the ability to analyse ethical dilemmas with empathy and compassion(J Relig Health. 2013 Jun 23)

·         Student feel gaps in ethics education basically because the field is fluid … no fixed boundaries

RESIDENTS’ CONCERNS

·         Recent pediatric graduates felt gaps in their ethics education(J Pediatr. 2013 Oct;163(4):1196-201)

·         Psychiatric residents needed more on boundaries and relationships(Acad Psychiatry. 2009 Nov-Dec;33(6):461-9)

·         Egyptian residents dissatisfied with their ethics training(East Mediterr Health J. 2012 Aug;18(8):827-35)

·         US Psychiatry residents wanted emphasis on informed consent, professional principles, and care of vulnerable populations(Acad Psychiatry. 2011 May-Jun;35(3):184-90)

·         Residents strongly agreed that clinical supervision and direct observation of patient interactions is appropriate assessment method (Acad Psychiatry. 2013 Jun 14).

AN ISLAMIC HOLISTIC APPROACH TO EDUCATION AND TRAINING

·         Traditional Muslim education based on a student being with the teacher all through the waking hours and being awarded permission to teach others, ijazah, at the end of a long apprenticeship

·         The system was not only about transferring knowledge but also transferred ethics, behavior, and attitudes by actual observation and interaction with a mentor.

·         The Qur’an describes this system in the education of Musa (PBUH) who travelled with the righteous man Khidhr and learned deep ethical lessons from him.

·         The prophetic teaching at Dar al Arqam: one to one, observation

·         Hadith: words, actions, and iqrar

TEACHING ETHICS AND PROFESSIONALISM BY MENTORING FITS THE ISLAMIC TRADITION

·         Rules and regulations relating to ethics and professionalism can be taught as a curricular subject.

·         The attitudinal, conceptual, and behavioral dimensions of professionalism and ethics cannot be taught didactically. These can be only be taught by interaction with righteous mentors whose words, actions, attitudes, and thoughts convey righteousness, ethics, and professionalism.

·         The challenge is to develop ethics and professionalism by adapting the traditional Muslim education system.

·         To achieve this, medical schools will have to be selective in recruiting who teaches their students especially in the crucial clinical phase and will have to monitor those professors to make sure they fulfill their mentorship roles.

SOURCES OF ETHICS IN ISLAMIC LAW

·         Source of ethics is the Law itself since Islamic Law unlike secular law integrates positive law and morality in one consistent legal system.

·         Paradigms and principles of the Law will have to be integrated in the medical

·         Purposes of the Law, maqasid al shari’at, constitute the Islamic theory of ethics: morality, life, progeny, intellect, and resources

·         Principles of the Law, qawa’id al fiqh, constitute Islamic ethical principles: 1. Sincerity of intentions (qasd),2. Evidence-based certainty (yaqeen), Benefit-injury considerations (dharar), Waiving rules in situations of difficulty (mashaqqat),following and respecting procedures ( ‘aadat)

·         The 4 principles (autonomy, beneficence, nonmalefacence, and justice) subsumed underdharar.

·         Empirical experience and ijtihad

7 DIMENSIONS OF PROFESSIONALISM: based on Islamic paradigms, mafaahiimislamiyyat, and world view, tasawwurislami

1.      Faith (iman)

2.      Consciousness (taqwat)

3.      Best character (ahsan al akhlaq),

4.      Excellent performance (itqaan al ‘amal),

5.      Strife toward perfection (ihsan),

6.      Responsibility (amanat),

7.      Self-accountability (muhasabat al nafs).

10 DIMENSIONS OF MEDICAL EDUCATION

1.      Ihsan (excellent quality)

2.      Takamul (integration)

3.      Shumuliyyat (comprehensiveness),

4.      Tawazun (balance),

5.      E’itidal (equilibrium),

6.      Tadafu’u (action-reaction)

7.      Khidmat (service),

8.      Qiyadat (leadership),

9.      Talab al ‘ilm (continuous life-long learning through study and research)

10.  Nashr al ‘ilm (disseminating knowledge).

ETHICS AND CURRICULUM AS PART OF PERSONAL AND PROFESSIONAL DEVELOPMENT- YEAR 1

YEAR, SEMESTER, & QUARTER	P R O F E S S I O N A L  &  P E R S O N A L   S K I L LS   D E V E L O P M E N T(12.5%)
	ETHICO-LEGAL-FIQH SKILLS	PROFESSIONALISM & PERSONAL DEVELOPMENT	RESEARCH SKILLS
Y1 S1 Q1 ( 8 Wks): Normal Life Processes	Religion, belief systems, & epistemology	Success as a medical student.	Mathematical and conceptual foundations
Y1 S1 Q2 ( 8 Wks): Abnormal Life Processes	Legal and ethical basis of medical practice	Personality & character	Descriptive statistics
Y1 S2 Q 1 (8 Wks): Transport Organ Systems[1]	Beginning and end of life issues	Communication skills	Inferential statistics
Y1 S2 Q 2 (8 Wks): Input/Output Organ Systems[2]	Public health and legal issues	Negotiation skills	Quantitative disease measures

ETHICS AND CURRICULUM AS PART OF PERSONAL AND PROFESSIONAL DEVELOPMENT- YEAR 2

YEAR, SEMESTER, & QUARTER	P R O F E S S I O N A L  &  P E R S O N A L   S K I L L   D E V E L O P M E N T(12.5%)
	ETHICO-LEGAL-FIQH SKILLS	PROFESSIONALISM & PERSONAL DEVELOPMENT	RESEARCH SKILLS
Y2 S1 Q 2 (8 Wks): Command, Control, & Communication Organ Systems[3]	Issues in multi-system disorders: systemic patho-physiological disturbances	Management skills for health services	Data collection and management
Y2 S2 Q1 ( 8 Wks): Reproductive Systems & The Life Cycle, growth and development	Issues in normal and disease conditions	Collegial relations / etiquette in a health team	Data analysis
Y2 S2 Q 2 (8 Wks): Transport Organ Systems	Issues in disease conditions	Physician-patient etiquette / relationship	Observational epidemiological studies

ETHICS AND CURRICULUM AS PART OF PERSONAL AND PROFESSIONAL DEVELOPMENT- YEAR 3

YEAR, SEMESTER, & QUARTER	P R O F E S S I O N A L  &  P E R S O N A L   S K I L L   D E V E L O P M E N T(12.5%)
	ETHICO-LEGAL-FIQH SKILLS	PROFESSIONALISM & PERSONAL DEVELOPMENT	RESEARCH SKILLS
Y3 S1 Q2 (8 Wks): Support, Locomotion, & Protective Organ Systems	Issues in disease conditions	Palliative care. / disability care	Analysis of epidemiological studies
Y3 S2 Q1 (8 Wks): Command, Control, & Communication Systems	Issues indisease conditions	Professional misconduct	Interpretation of epidemiological studies
Y3 S2 Q2 (8 Wks): Reproductive Systems	Issues in disease conditions	Professional malpractice / negligence	Critique and writing of scientific literature

ETHICO-LEGAL CURRICULUM: BACKGROUND PHILOSOPHY and CONCEPTS (5%)

·         Religious Background: Islam & Other Creeds (Milal)

·         Historical Background: Civilization, History Of Medicine

·         Epistemological Background: Theory Of Knowledge (Epistemology)

·         Basic Sciences Background: Creation (Cosmogenesis / Genesis) And Afterlife (Eschatology). Transitions In The Status Of Life And Health. The Human Life Cycle (Growth And Senescence). The Biological Miracle

ETHICO-LEGAL CURRICULUM: ETHICO-LEGAL-FIQH CONCEPTS / PRINCIPLES (20%)

·         Basics Of Laws: Fundamentals Of The Law. The Legal Systems: Civil And Shari’at Laws

·         Theories And Principles Of Medical Ethics: Theories Of Medical And Biomedical Ethics. Principles Of Medical And Biomedical Ethics

·         Issues Of Consent: Medical Consent For Competent Patients. Medical Consent For Incompetent Patients

·         Privacy, Confidentiality And Disclosure: Privacy And Confidentiality. Disclosure

·         Research: Research Policies And Procedures. Animal Research. Human Research

ETHICO-LEGAL CURRICULUM: ETHICO-LEGAL-FIQH ISSUES IN MEDICAL PRACTICE (20%)

·         Normal Physiological Conditions: Issues In Normal Reproduction.

·         Issues In Activities Of Normal Living.

·         Medical Procedures: Diagnostic Procedures. Therapeutic Procedures

·         Conditions Of Illness: Physical Acts Of Worship For The Sick.

·         Input/Output Systems: Alimentary And Urinary.

·         Transport Systems: Cardiovascular & Respiratory.

·         Reproductive System.

·         Locomotion, Support, And Connective System.

·         Sensory System. Neurological Disorders. Psycho-Social Conditions.

·         Other Conditions. Issues Of Special Age And Gender Groups

ETHICO-LEGAL CURRICULUM: ISSUES AT THE BEGINNING AND END OF LIFE (5%)

·         Beginning Of Life Issues.

·         Stem Cell Technology.

·         Embryo/Fetal Research.

·         Genetic Technology.

·         End Of Life Issues

ETHICO-LEGAL CURRICULUM: ETHICO-LEGAL-FIQH ISSUES IN PSYCHO-SOCIAL APPLICATIONS (5%)

·         The Community: The Family Institution. Community Problems. Community Action. Civil Transactions. Occupational Health Issues.

·         Judicial Transactions: Legal Competence: Ahliyyat. Public Health Ethics

ETHICO-LEGAL CURRICULUM: PROFESSIONALISM (15%)

·         Professional physician etiquette / conduct with patients.

·         Professional etiquette with the terminally ill/dying: palliative care.

·         Collegial relations / etiquette in a health team.

·         Professional misconduct, Malpractice & negligence

ETHICO-LEGAL CURRICULUM: PERSONAL DEVELOPMENT (5%)

·         Individual development: Success as a medical student.

·         Towards developing a scientific culture.

·         Character and behavior.

·         Self Development and personality enhancement

·         Skill development: Communication.

·         Negotiation skills. Leadership Skills. Management Skills for health services

ETHICO-LEGAL CURRICULUM: RESEARCH (scientific ijtihad) SKILLS (25%)

·         Mathematical and conceptual foundations.

·         Descriptive statistics.

·         Inferential statistics.

·         Descriptive & inferential statistics applications.

·         Quantitative disease measures.

·         Study design and analysis. Study interpretation

ETHICS CASES WITHIN THE PBL SYSTEM – YEAR 1

·         A patient on long-term calcium treatment for osteoporosis developed an infection found on culture and sensitivity to be highly sensitive to tetracycline. She did not improve on treatment with an adequate dose of tetracycline after 10 days.  The GP treating her did not know about her calcium medication. The case was referred to a consultant who instantly found the reason for non-response.

·         Discuss ethico-legal issues that arise in this case

ETHICS CASES WITHIN THE PBL SYSTEM – YEAR 2

·         An HIV epidemiologist tested leftover lab blood samples anonymously for HIV. He found one sample positive but could not disclose. He advised the clinic to retest all patients seen on a specific day together with their spouses telling them the test was for malaria. He advised that those found positive should be given counseling and retested for HIV according to the rules. A couple was found HIV+VE. The husband refused anti-retroviral treatment but the pregnant wife agreed. When she developed reactions to the only drug available the clinic pretended to change it but actually out her again in the same drug without her knowledge for the sake of the fetus.

·         Discuss ethico-legal issues in HIV testing without consent in a patient suspected of being infected. 2. Discuss the ethico-legal issues in disclosing HIV status 3. Discuss legal issues in forcing an HIV +ve patient to take medication;

THE MOOT COURT 1

CASE #1:

Plaintiff:                      General Hospital

Defendant:                  Jaya Orphanage

Judge:                          Justice from the Brunei High Court

Dr Aisha, a 28-year old single radiologist was the head of department supervising 20 assistants and reading all the radiology films. She was the only remaining radiologist in the country after death of her colleague last year from leukemia. Three months ago she got a diagnosis of end stage renal failure requiring kidney transplantation. A blood film made in routine investigations while on the ward revealed multiple myeloma. The hospital director was very concerned about getting her the best medical care because she was the only radiologist in the country. He tried his level best to find matching kidney and bone marrow donors with no success for over 3 months.

THE MOOT COURT 2

When asked whether she had any relative who could be a donor Dr Aisha remembered that she had only one surviving relative. She was a 14-year old sister, Maryam, who was born with cerebral palsy and was cared for at an institution for handicapped orphans. Dr Aisha’s mother and 2 other sisters died in an air crash 10 years ago. Dr Aisha, her father, and a younger sister called Maryam survived the crash. The father died 3 months later from complications of injuries from the crash. Before dying, he had signed legal papers awarding custody of Maryam to the orphanage.

THE MOOT COURT 3

The hospital director approached the orphanage to obtain tissues for matching. The Director of the orphanage refused saying that he had no authority to decide on behalf of Maryam and that Maryam did not have enough cognition even to understand the issue. He also argued that it was not in Maryma’s best interests to be a donor in this situation. He explained that the orphanage belonged to the government and that custody of Maryam was eventually in the hands of the Ministry of Social Welfare.

THE MOOT COURT 4

A team of psychiatrists from the General Hospital examined Maryam and found that she had limited cognition equivalent to that of a 4-5 year old child. When asked about her sister she said she hated her because she had never visited her at the orphanage. The psychiatrists did not submit any report about Maryam’s competence to the hospital director.

THE MOOT COURT 5

 The hospital director took the case to a lower court that then ruled in favor of the orphanage. The judge refused an application by the hospital director to treat kidney tissue matching separate from bone marrow matching. The judge rejected the application and treated the 2 issues together rejecting both requests for tissue matching. The hospital director appealed to the High Court.

EXAMPLE OF MCQ EXAM QUESTION

1. A couple with an anencephalic fetus at 28 weeks of gestation seek your advice on what to do. Which of the following statements is an appropriate response?

a.      That fetus is as good as dead, I will abort it and let you get on with your lives

b.      There is no point carrying the pregnancy to term, the fetus will not survive but I will not tell you what alternatives are available because of my religious beliefs

c.       I would advise abortion but I will not carry it out myself because of my religious beliefs but I can direct you to a doctor who will carry it out

d.      It is all up to you. Decide what you want and tell me what to do. I am doctor and not an ethicist

e.      None of the above

EXAMPLE OF A SAQ EXAM QUESTION 1

Mumtaz is a 40-year old lawyer married to a businessman. For 20 years of her marriage she could not have a baby because she had fallopian tube obstruction and the husband had a low sperm count. Against the wishes of her husband she decided to try invitro fertilization using sperms donated from a sperm bank. The operation was successful and she became pregnant.

Q1. What ethico-legal problem can you identify at this stage?

EXAMPLE OF A SAQ EXAM QUESTION 2

Her obstetrician was worried about the baby because it was precious and wanted to make sure nothing went wrong. He therefore suggested amniocentesis for ante-natal screening. Mrs Mumtaz refused promptly and was supported by her husband.

Q2. What is your opinion about carrying out amniocentesis in this case? Give reasons to support your argument.

EXAMPLE OF A SAQ EXAM QUESTION 3

Towards the end of pregnancy, the obstetrician advised Mrs Mumtaz to agree to an elective caesarian section and not go through labor because it would be risky for the baby of such an old mother.

Q3. What is your opinion about the obstetrician’s advice? Give reasons supporting the elective caesarian section and reasons against it.

EXAMPLE OF A SAQ EXAM QUESTION 4

Mrs Mumtaz turned down the suggestion of al elective caesarian section. When she went into natural labor, fetal distress was diagnosed promptly by the obstetrician and he advised immediate caesarian section. Mrs Mumtaz agreed but her husband refused. The obstetrician went ahead to carry out the operation and delivered a healthy baby.

Q4. Was the obstetrician right to carry out an operation against the wishes of the patient? Give reasons to support your argument

Q5. Discuss the conflict between maternal rights and fetal rights in this case and give your view based on ethical principles and the rights theory

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[1]CVS, BLHematogenous, & Respiratory

[2]GIT, Hepato-biliary, & excretory

[3](sensory, nervous, and endocrine).