Brewin TB (Lancet 1993)

"How much ethics is needed to make a good doctor?"

3 qualities of a good doctor; motivation: "put yourself in the patient's place" judgment: sound judgment rapport: all aspects of communication

Can we teach these qualities to students? 　　　　 "Yes, through thorough discussion of the pros and cons of difficult dilemmas " (not through academic ethics)

Bioethics Education in Medical School

Compulsory for first-year students

Term: 14 to 15 school hours

Content: group discussion & lectures

Clinical cases: truth disclosure and Jehovah’s witnesses

Whole-class session after group discussion

Evaluation: ethical test, reports submitted after group 　　　　　　　　　　　　 discussions, the course attendance rate

Medical Ethics Course in HCM

The aim of this paper:

　　 to introduce our 3 year-experience in bioethics 　　 　　　　 education though teachers’, students’ and tutors’ eyes

　　 　 　 2000 　　　 2001 2002

Number 　　 　 　 　 100 98 99

　 male 　　　 　 　 53 58 60

　 female 　 　 　 47 40 39

Age (years) 　 　 19.8 19.2 20.1

Attendance rate (%) 　 86 　 96 99

Final comments (No) 23 52 21

Backgrounds of Students

(continuous variables: average)

1 　 informed consent in children

2 　 immunity to malpractice at admission

3 　 truth: first to the family, then to the patient

4 　 family’s consent is enough in cancer

5 　 best treatment is done without patient consent

6 　 patient’s privacy (health information)

7 　 patient’s privacy (document)

8 　 blood transfusion without patient’s consent

9 　 patient’s right to know

10 　 emergency medicine without consent

Ethical Tests on the First and Last Day

Maximum 10 points

Ethical Tests on the First and Last Day

　　 　 　 first test final test

2000 7.1 (6.8 - 7.4) 7.4 (7.1 - 7.6)*

2001 7.6 (7.3 - 7.9) 7.5 (7.2 - 7.7)

2002 5.6 (5.3 - 5.8) 7.7 (7.5 - 8.0)** mean (95% confidence interval), statistically significant

between the first and final test (*P<0.01, ** P<0.001)

Evaluation of Students’ Reports

Counting number of key words in their reports

e.g. patient’s right → 1, informed consent → 1

patient’s right based on Lisbon Declaration → 2

informed consent based on patient’s right → 2

* In-depth description can attain higher scores !

Example

　　 　 Ethical issues in truth disclosure

2000 58 (51 - 65)

2001 62 (56 - 68)*

2002 55 (52 - 58)* mean (95% confidence interval), *p<0.050

Factors Contributing to Evaluation of Students (2000)

odds ratio 　 95% C.I. p value

Age 1.08 0.67 - 2.00 0.52

Gender (male=1.00 ） 0.64 0.03 - 4.31 0.42

Attendance rate 1.22 1.16 - 2.15 0.0001

Ethical test, first 1.14 0.59 - 3.04 0.47

last 2.14 1.53 - 22.22 0.009

Report score

Case 1, 1st group discussion 0.97 0.83 - 1.06 0.37

　 2nd group discussion 1.00 0.91 - 1.10 0.90

Case 2, 1st group discussion 0.95 0.63 - 1.25 0.51

　 　 　 2nd group discussion 1.00 0.95 - 1.05 0.95

Separate analysis regarding tests

First test 0.84 0.33 - 1.37 0.27

Last test 1.80 1.44 - 10.3 0.006

1 Clinical case-based discussion is possible in first-year students.

2 Group discussion is functioning.

3 Report score correlated with the last ethical test, but not with the first test.

4 The last test was a contributing factor to the acceptance level.

5 Conclusion: the ethics course was useful for the students to increase reflectiveness regarding ethical thinking.

Summary of Evaluation by Teacher (2000)

Questionnaire regarding Course by Students (2000&2001)

Guidance: Understandable? 　　　　　　　　　　　　　　　　 Understood the method of case analysis?

Case discussion: Were issues classified? Presented well? 　　　 Was evaluation method fair? Was Case 1 appropriate? 　　　　 Was Case 2 appropriate? Were two cases too many?

Lecture: Basis of clinical ethics? Bioethical thinking? 　 Death/brain death/organ transplant? Were topics appropriate?

Debate: Understood the method? Were issues classified? 　　　　 Was your thinking altered?

Whole course: Understood the method of case analysis? 　　　　　　 Were lectures useful? Was debate useful? 　　　　　　　　　　　　　 Was the course useful? Was group size appropriate? 　　　　　　 Were teachers active? Was the course too long?

Originally a five-point Likert scale. Summarized to 3 point, negative/middle/positive answer by percentages.

Response of Students (2000&2001)

Questions 　　　　 　 2000 2001 χ ２　 p value

Analysis method 28/38/34 13/22/65 14.948 0.0006

Lectures 15/40/45 4/27/69 12.058 0.0024

Debate 22/49/29 15/31/55 11.377 0.0034

Course 16/35/50 10/24/67 5.145 0.0763

Group size 42/33/25 64/19/17 8.179 0.0167

Teacher 5/26/68 6/20/76 1.188 0.5521

Length 26/43/31 53/38/9 18.946 <0.0001

1 Medical ethics course 2000: group size 10 students

　　 2001: group size 7 to 8 students, tutorial method

2 A majority showed positive attitudes to the course

3 2001 students showed more affirmative answers in more 　 than half of evaluated items than the 2000 students

4 The difference appears to stem from more lively discussion by the introduction of tutorial system and reducing the number of students in discussion groups in the latter-year course.

Summary of Students’ Response (2000&2001)

Questionnaire on Students’ Performance (2001&2002)

2001: Group-based manner, 8 items 　

　　 Understood the method, All participated in discussion,

　　 Discussed multi- dimensionally, Used own knowledge

　　 Role was decided soon, Discussion was active

　　 Summarized in time, Reduce the group size

2002: individual-based manner, 2 items

　 Discussed actively, Responded flexibly

Answer 2001: a 5-point Likert scale 　　 2002: 5 degrees

Correlation of Students’ Performance in Discussion

Understood All participated Discussed Use own Role was Discussion Summarized

the method in discussion multi-dimensionally knowledge decided soon was active in time

All participated .734 　　　　　　　　　　　　　　　　　　　　　　　　　　 in discussion (.003) 　　

Discussed .604 　　　　　 .734 　　 　　　　　　　　　　　　　　　　　　　　　　　　　　　 multi-dimensionally 　　 (.022) 　　　　 　 (003)

Used own 　　　 　 .669 　　　　　　 .698 　　　　　　 .739 　　　　　　　　　　　　　　　　　　　　　　　　　　　　　 knowledge 　　　　 　 (.009) 　　　　　 (.005) 　　　 　　 (.003)

Role was 　　　 　 .684 　　　　　　 .608 　　　　　　 .368 　　 　　　 .429 　　　　　　　　　　　　　　　　　　　　　　 decided soon 　　　　 　　 (.007) 　　　　　 (.021) 　　　 　 (.196) 　　　 (.126)

Discussion 　　 　　 .569 　　　　　　 .865 　　　　　　 .517 　　　 　　 .563 　　　 　 .525 　　　　　　　　　　　　　　　 was active 　　　　　　　　　 (.034) 　　　　　 (.000) 　　　　　 (.058) 　　 　　 (.036) 　　　　 (.054)

Summarized 　　　 .796 　　　　　　 .708 　　　　　　 .473 　　 　　　 .528 　　　　　 .529 　　　　　 .480 　　　　　　　　 in time 　　　　　　　　　 　　 (.001) 　　　 　　 (.005) 　　　　　 (.088) 　　　　 (.053) 　　　　 (.052) 　　 　　 (.082)

Reduce the 　　　 　 -.570 　　　 　　 -.723 　　　 　　 -.421 　　 　　 -.574 　　　 　 -.360 　　 　　 -.624 　　　　 -.405 　　 group size 　　　 　　 (.033) 　　　　　 (.003) 　　 　　　 (.134) 　　　 　 (.032) 　　　　 (.206) 　　　　 (.017) 　 　 (.151)

More lively discussion correlated with more active participation of students to discussion by tutors’ eyes.

(2001)

　 　

　

Correlation of Students’ Performance with Evaluation

Case: discussion on truth disclosure

Discussed actively 　　 1.000 　　 .802 (.000)

Responded flexibly .802 (.000) 1.000

Report score .341 (.001) .323 (.003)

Final assessment 　　　 .270 (.007) .230 (.038)

Discussed actively Responded flexiblycorrelation coefficient (p value)

(2002)

Odds ratio (95%CI) of regression analysis. As students started and discussed PBL without tutors’ order or intervention, odds ratios would increase. *Statistically significant. NC: not calculated.

Students’ Performance and Tutors’ Intervention

　　　　 　 Started as 　　　　 　　　 Intervention 　　　　　　　　　　　　　　 instructed 　　　　 　　 unnecessary

First discussion,

discussed actively 0.49 (0.02 - 1.72) NC

responded flexibly 9.09 (5.26 - 500) * NC

Second discussion,

discussed actively NC 1.23 (0.20 - 12.7)

responded flexibly NC 2.71 (1.26 - 78.1)*

Third discussion,

discussed actively 0.41 (0.005 - 500) 0.49 (0.01 - 3.31)

responded flexibly 0.60 (0.01 - 6.71) 0.68 (0.02 - 6.88)

Students’ Comments on the Course

1 Most answers were affirmative to this bioethics course e.g., discussed subjects never thought about

　　　　 knowing different opinion is fruitful　　　　　　　 difficult to discuss problems without right

answer personal growth, changed my view toward themes

2 Some students wanted to learn knowledge of ethics

3 A few students claimed discussion not based on proper answer is useless or non-sense.

Bioethics Education in Medical School

1 Clinical case-based group discussion is functioning well.

2 The ethics course was useful for the students to increase reflectiveness regarding ethical thinking.

3 To enhance discussion, tutorial system is useful.

4 There were some students who wanted more knowledge.

5 Tutors rated flexibility in response to other opinions as an important factor in discussion.

6 Need to establish reasonable assessment method.

Bioethics Education in Medical School

Bioethics Education vs Medical Ethics Education

Bioethics education = more patient-centered

Medical ethics education = more clinically centered 　　　　　　　　　　　　　　　　　　　　 (Miles SH et al, Acad Med 1989)

　　 Question: when doctors’ awareness on ethics are improved, 　　　　　　 　　　 then will doctors become more ethical?

Answer: ?

Clues to the answer

The current medicine: based on belief in limitless advance 　　　　　 Reality: life expectancy cannot be extended any longer by　　　　　　　　　　 medical science. 　　　　　　　　　　　　　　　　　　　　　　　　　　　 Example: Japan has sent sophisticated incubators to improve 　　　　　　　　　　 neonatology in Afghanistan.