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.